Management of gastric variceal bleeding

We read with interest the article by Jang et al. [1] about a case of gastric variceal bleeding that was treated by endoscopic band ligation (EBL). Treatment of gastric varices with EBL has been reported to cause massive and fatal bleeding from EBL-related ulceration [2]. We therefore believe that EBL for the treatment of gastric variceal bleeding was an inadequate management. The best preventive approach for gastric variceal bleeding has been believed to be surgery [3]. However, its high invasiveness has limited the wide application of the procedure because these patients usually have poor hepatic functional reserve [3]. Although percutaneous transhepatic obliteration (PTO) is a well-established technique in the management of gastric variceal bleeding, the procedure is associated with a high incidence of rebleeding and recurrence [3]. Transjugular intrahepatic portosystemic shunt (TIPS) is considered to be a rescue option for variceal bleeding unresponsive to pharmacological and endoscopic treatment. However, TIPS has major disadvantages, such as stenosis and occlusion of the shunt, high rebleeding rates, and induction of hepatic encephalopathy [3], and might be ineffective for gastric varices with a gastrorenal shunt because of low portosystemic gradients [4].

The management of gastric variceal bleeding is still a great challenge for endoscopists [5]. Because of massive bleeding due to the fast and copious blood flow, ruptured gastric varices are usually intractable, and show high mortality and rebleeding rates [3] [5] [6] [7]. Conventional endoscopic injection sclerotherapy (EIS) with several sclerosants has been reported to be ineffective for the treatment of gastric varices because the sclerosants are easily diffused by the copious blood flow with the loss of thrombotic effect [3] [6]. As a result of its excellent efficacy, EIS with cyanoacrylate is considered to be the optimal initial treatment for bleeding gastric varices, and for secondary prophylactic eradication of gastric varices [6] [7]. The cyanoacrylate can embolize blood vessels almost immediately and completely after injection, by forming a polymer [8]. Although Jang et al. [1] used EBL for the treatment of gastric variceal bleeding, EBL has been found to be less effective than EIS with cyanoacrylate in arresting gastric variceal bleeding [5] [6], and had higher rebleeding and mortality rates because of inability to contain varices in their entirety in the ligator [4] [5].

After initial hemostasis had been achieved, the existence of a gastrorenal shunt should have been confirmed in order to determine the most appropriate therapeutic strategy, because most gastric varices are associated with a shunt [9]. Balloon-occluded retrograde transvenous obliteration (B-RTO) is a safe and effective treatment for gastric varices with a shunt [2] [10] [11]. In a study of the clinical efficacy of management of gastric varices with endoscopic therapy, surgery, and interventional radiology (IVR) including B-RTO, IVR was the most effective procedure for arresting active bleeding [12]. B-RTO should be performed within 24 hours after the initial hemostasis because of the high risk of early rebleeding [3]. The main limitation of B-RTO is that in an emergency setting it requires the temporary control of bleeding [11].

EIS using cyanoacrylate and B-RTO are therefore the procedures mainly used to treat gastric varices [2]. For the management of bleeding gastric varices associated with a gastrorenal shunt, we recommend the use of B-RTO after achieving initial hemostasis by EIS with cyanoacrylate. If EIS with cyanoacrylate is unavailable, because of a lack of cyanoacrylate or of technical expertise, EBL might be used as a temporary means to arrest active bleeding, and should be followed by early B-RTO.

Competing interests: None

References

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